Hydatid mole (GTD) is a trophoblast proliferation re- sulting from abnormal differentiation of a fertile egg cell.
In Poland, GTD is recognized in one case out of 2000 pregnancies. The diagnosis is based on histopathological
examination of tissue removed from the uterine cavity. In a majority of cases, a whole hydatid mole is removed from the uterus. However, in some patients, the parts of trophoblast may remain and produce chorionic gonado- tropin (HCG). Persistent trophoblastic disease is reco- gnized in such cases. The quantity of HCG depends on the mass and histopatological type of tumor. HCG blood level is often very high.
NOWOTWORY 2001/ tom 51 Zeszyt 3 / 241–244
The value of hysteroscopy in the diagnosis and treatment of persistent trophoblastic disease
- a preliminary report
Mariusz Bidziƒski
B a c k g r o u n d. Persistent trophoblastic disease (PTD) may cause a diagnostic and therapeutic dilemma. Hysteroscopy helps to inspect the uterine cavity, allows to take the biopsy and also to remove the tumor. The purpose of this study was to es- timate the value of hysteroscopy in the diagnosis and treatment of PTD under visual control.
M a t e r i a l a n d m e t h o d s . Since 1995 to 1999 ten patients with PTD were treated with the use operative hysteroscopy. The initial diagnosis was obtained using USG examination.
R e s u l t s. The tumor was visualised by hysteroscopy in all patients. Removal of tumor resulted in over 84% reduction HCG level in 9 patients. In these cases the volume of the tumor did not exceed 4cc. Partial tumor resection was done in the re- maining case with larger volume due to excessive bleeding.
C o n c l u s i o n. This preliminary report indicates that hysteroscopy may be effective in diagnosis and treatment of patients with persistent trophoblastic disease.
WartoÊç histeroskopii w diagnostyce i leczeniu przetrwa∏ej cià˝owej choroby trofoblastycznej - doniesienie wst´pne
W s t ´ p. Przetrwa∏a cià˝owa choroba trofoblastyczna (PTD) mo˝e stanowiç problem terapeutyczny. Pomimo doskona∏ych wy- ników chemioterapii, w przypadku izolowanych ognisk w macicy, istnieje mo˝liwoÊç ich usuni´cia przy u˝yciu histeroskopii.
W ten sposób eliminujemy koniecznoÊç stosowania leczenia uzupe∏niajàcego lub ograniczamy liczb´ wlewów chemioterapii.
Docelowà korzyÊcià jest zmniejszenie lub wyeliminowanie toksycznych efektów chemioterapii. Histeroskopia pozwala dok∏ad- nie uwidoczniç endometrium, pobraç materia∏ do badania histopatologicznego, a tak˝e usunàç patologiczne ogniska w ma- cicy. Celem pracy by∏a wst´pna ocena przydatnoÊci histeroskopii do leczenia chorych na PTD.
M a t e r i a ∏ i m e t o d y k a. Badaniem obj´to grup´ 10 chorych z rozpoznaniem PTD, leczonych w latach 1995-1999. U wszyst- kich chorych, za pomocà badania USG, uwidoczniono przetrwa∏e ogniska choroby w macicy. Stosujàc technik´ histerosko- pii operacyjnej, usuwano patologiczne ogniska z macicy.
W y n i k i. U 9 chorych wykonany zabieg spowodowa∏ obni˝enie st´˝eƒ HCG powy˝ej 84% w stosunku do st´˝enia wyjÊciowe- go. U jednej chorej z guzem o obj´toÊci 7,4 cm3zabieg powik∏any by∏ krwawieniem z wn´trza macicy, co uniemo˝liwi∏o dok∏ad- ne wyci´cie zmiany. Dwie chore po wykonaniu histeroskopowej resekcji nie wymaga∏y ˝adnego uzupe∏niajàcego leczenia. Opty- malny wynik zabiegu uzyskiwano przy obj´toÊci guza nie przekraczajàcej 4 cm3.
W n i o s k i. Pomimo wst´pnego charakteru doniesienia nale˝y podkreÊliç, ˝e metoda potwierdzi∏a swojà przydatnoÊç w lecze- niu chorych na przetrwa∏à cià˝owà chorob´ trofoblastycznà.
Key words: gestational trophoblastic disease, hysteroscopy, ultrasound
S∏owa kluczowe: cià˝owa choroba trofoblastyczna, histeroskopia, ultrasonografia
Department of Gynecological Oncology
The Maria Sk∏odowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
The removal of hydatid mole tissue is difficult due to a considerable softness of uterus wall caused by tropho- blast infiltration and congestion of myometrium. Therefo- re, some interventions are inconclusive. Hysteroscopy al- lows a more precise inspection of the uterine cavity and, eventually, the removal of the remaining parts of the mo- lar tissue. It may limit or eliminate chemotherapy in indi- vidual cases.
The purpose of this study was to estimate the useful- ness of hysteroscopy in diagnosis and removing of patho- logical tissue under visual control.
Materials and methods
Since January 1995 to July 1999 ten patients with microscopical- ly confirmed non metastatic persistent trophoblastic disease we- re treated with the use of operative hysteroscopy. The time gap after uterine cavity curretage ranged from 2 to 5 months. Persi- stent elevated level of HCG was the indication for operation. Di- stant spread was excluded by imaging techniques.
HCG blood concentration was determined two hours befo- re operation and two and seven days after hysteroscopy procedu- re. Whole removed tissue was sent for histopatological examina- tion.
In addition, the size of molar tumor assessed by transvagi- nal USG was compared with that obtained by hysteroscopy.
Storz resectoscope with Hamou II optics was used. Uterine cavi- ty was filled with 1.5% glicyne solution by Storz endomat. Resec- toscope was connected to a Storz Autocon 350 surgical diather- my. This type of equipment allows not only to cut tissue, but also to coagulate with a „spray” function, enabling a fast and ef- fective haemostasis. All procedures were performed under gene- ral anesthesia.
Results
The volumes of the tumor ranged 0.8-7.4 cc, was shown by transvaginal USG examination performed before hystero- scopy. The values of HCG blood concentration and re- sults of USG examination before and after the treatment are presented in Tables I and II.
Pathological lesions in the uterine cavity were shown during hysteroscopy in all patients. Majority of them lo- oked like a polypus with light red color. Their surfaces bleeded after a soft touch. The time of operation ranged between 7 and 35 minutes. All visible lesions were remo- ved in nine cases. In the remaining case only partial tumor resection was done due to of the size of tumor and inten- sive bleeding. Only a slight decrease of HCG blood level and tumor size as assessed by USG examination was obse- rved (patient 1). No complications during and after ope- rations were observed (see Tables I and II).
Histopathological examination showed choriocarci- noma in 3 patients, invasive mole in one case and hydatid mole in the remaining cases. Chemotherapy was introduced in 8 patients due to persistence of higher HCG blood concentration. In two patients (case 9 and 10), such treatment was not required. HCG blood levels returned to normal three weeks after hysteroscopy.
Discussion
Residues of hydatid mole inside uterine cavity may lead to the development of persistent gestational trophoblastic di- 242
Tab. I. HCG blood levels in patients with PTD before and after hysteroscopy
No HCG – before HCG – 2 days after HCG – 7 days after Percent of HCG decrease in 7th day in treatment (IU/l) hysteroscopy (IU/l) hysteroscopy (IU/l) comparison with initial level
1 300000 283000 254670 15%
2 111245 62200 17572 84%
3 22108 17320 380 98%
4 19110 17920 512 97%
5 17435 11932 1202 93%
6 11200 7429 1206 89%
7 9870 1759 174 98%
8 7205 1274 183 97%
9 1125 417 79 93%
10 720 104 26 96%
Tab. II. The volume of uterine lesions before and after hysteroscopy treatment
No USG before USG – 2 days after USG – 7 days after Percent of decrease of tumor
hysteroscopy (cc) hysteroscopy (cc) hysteroscopy (cc) capacity in 7 days in comparison with initial size
1 7.4 5.3 6.2 16%
2 4.2 1.4 1.2 71%
3 2.1 1.1 1.2 43%
4 2.4 1.5 0.8 67%
5 1.7 0.7 0.4 76%
6 2.1 1.3 0.9 57%
7 3.1 1.1 0.8 74%
8 1.1 0.4 0 100%
9 1.0 0.3 0 100%
10 0.7 0.4 0 100%
sease (PTD). Such syndrom occures in 18-29% of pre- gnancies with complete mole, and 2-4% of patients with partial mole [1, 2]. Histologically PTD may have a nature of mole or choriocarcinoma. A distinction between these two types of trophoblast pathologies is crucial for optimal selection of treatment. The diagnosis of choriocarcinoma qualifies a patient to a high risk group and requires poli- chemotherapy [3]. Unfortunately, precise histological dia- gnosis of PTD is not always performed. This may result in a suboptimal treatment.
Berkowitz i Goldstein [4, 5] observed a resistance to chemotherapy in 6.4% cases of clinical stage I of GTD.
All these patients were included into a high risk group be- cause choriocarcinoma diagnosis.
Hysteroscopy, allows a precise evacuation of lesions from the uterine cavity. The magnification of picture al- lows to take a precise biopsy.
Hysteroscopy is not widely used in the treatment of PTD [6-10]. Our initial experience is very promising. In nine cases the tumor size was significantly reduced and HCG serum levels were also reduced. Two patients avo- ided chemotherapy after successful evacuation of molar tissue. This method may contribute to a reduction of the number of chemotherapy courses to obtain total remis- sion. The size of tumor influences the number of courses of chemotherapy. It is also a significant factor in statistical analysis [11].
Hystroscopic operations are more effective in pa- tients with small tumors, with the volume of less than 4 cc.
In such cases in our group HCG levels decreased by as much as 84%. Bigger tumors caused more technical diffi- culties and they should be qualified to the other type of therapy, or be done by a very experienced surgeon. The- re is a clear border between pathological changes and a normal tissue in small and limited tumors. The safety of operations is than higher. We suggest that patients with small tumors should be qualified to this method of treat-
ment. Electric resectoscope with a „spray” coagulation is very helpful in achieving effective haemostasis.
It should be stressed that endoscopy method of treat- ment limits a necessity of hysterectomy in cases in which the tumor is chemoresistent. Future investigations may re- sult in a more detailed evaluation of the advantages and eventual disadvantages of this method.
Conclusions
1. Hysteroscopy should be considered as a useful method of treatment of non metastatic persistent trophoblastic disease.
2. Hysteroscopy is particularly useful in small tumors (<4 cc). In such cases HCG blood levels decrease by as much as 84%.
Mariusz Bidziƒski M.D., Ph.D Department of Gynecological Oncology
The Maria Sk∏odowska-Curie Memorial Cancer Center and Institute of Oncology
Roentgena 5 02-781 Warsaw Poland
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Ryc. 1. The picture of choriocarcinoma lesion inside uterine cavity Ryc. 2. The picture of uterine cavity just after the removal of choriocarcinoma lesion
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Paper received: 19 September 2000 Accepted: 1 March 2001 244
